Provider Demographics
NPI:1760906580
Name:KELLY, TIMOTHY WHITE (MED ATC-L)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:WHITE
Last Name:KELLY
Suffix:
Gender:M
Credentials:MED ATC-L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9502 PROVIDENCE RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-8695
Mailing Address - Country:US
Mailing Address - Phone:704-846-7219
Mailing Address - Fax:
Practice Address - Street 1:9502 PROVIDENCE RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-8695
Practice Address - Country:US
Practice Address - Phone:704-846-7219
Practice Address - Fax:704-846-7219
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-02
Last Update Date:2017-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14032255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer